Assessment of haemostatic function in paediatric surgical patients: 'if you prick us, do we not bleed?'

Healthy babies have ∼50% of adult procoagulant factor levels, but without an increased risk of bruising or bleeding. The preoperative clotting tests, prothrombin time and partial thromboplastin time, are frequently performed in infants and children. However, the clinical usefulness of screening coagulation tests remains controversial. Viscoelastic coagulation tests are increasingly used to guide perioperative haemostatic interventions. Enhanced coagulability was previously demonstrated on some viscoelastic testing devices using blood from younger infants. This editorial focuses on several key findings from the paediatric reference range study using a new whole blood viscoelastic coagulation test system, ClotPro® (Haemonetics, Boston, MA, USA). Altered clotting patterns in younger infants, underlying mechanisms of coagulation, and potential clinical implications are discussed.

Effect of informational Spanish anesthesia video on the level of anxiety and uncertainty with Native Spanish speaking parents. A pilot study.

OBJECTIVES: We hypothesized that showing native Spanish speaking parents, a Spanish video explaining the risks and benefits of anesthesia within two weeks prior to surgery would reduce parental anxiety. METHODS: Subjects were randomly assigned to video-group or non-video-group. Both groups completed PPUS, STAIT and APAIS tests before and after viewing the videos. Parents repeated the same three tests before the operation on the day of the surgery. RESULTS: The results revealed a decrease in 3 points on the APAIS assessment in the non-video-group compared to 5.8 points decrease in the video-group. PPUS assessment revealed an average 1.25 points increase in the non-video-group compared to 11 points decrease in video-group. Due to the extremely low sample size, the statistical significance of the findings cannot be verified by statistical methods. CONCLUSIONS: Hispanic parents who viewed the preanesthesia Spanish-video had lower levels of anxiety compared to those who did not watch the video.

Assessment of anesthesia provides' opinions regarding pediatric induction practices in the state of Oklahoma.

OBJECTIVES: The induction of anesthesia in children is commonly carried out by the administration of inhaled anesthetics via face mask as opposed to an intravenous induction. Thus far, no study has assessed the opinions of anesthesia providers regarding commonly used induction techniques. We surveyed current attitudes among anesthesiologist to understand anesthesia induction techniques in pediatric patients in the community. BACKGROUND: A survey of community anesthesiologists induction of anesthesia methods in children was sent to members of the Oklahoma Society of Anesthesiologists. METHODS/MATERIALS: Three hundred and fifty-seven active members in the Oklahoma Society of Anesthesiologists (OSA) were sent a survey in a three-stage mailing process: 1) an introductory letter and questionnaire, 2) a follow-up reminder, and 3) a thank you letter to maximize response rate. RESULTS: 179 (84 percent) indicated they feel comfortable with the procedure. 77 percent of respondents rated their proficiency in administering pediatric anesthesia at least 8 on a scale of 1 to 10, where 10 denotes "excellent" proficiency. 188 (87 percent) reported they do not feel abusive. Among respondents, the median percentage of practice devoted to pediatric anesthesia was 10 percent. CONCLUSIONS: To evaluate pediatric anesthesia induction techniques, the attitudes of anesthesia providers were assessed. Although 84% of responders felt comfortable with pediatric patients and 77% felt proficient, our data suggests that further education and research can be done to help facilitate a higher percentage who feel comfortable with pediatric induction techniques.

Epidural anesthesia needle guidance by forward-view endoscopic optical coherence tomography and deep learning.

Epidural anesthesia requires injection of anesthetic into the epidural space in the spine. Accurate placement of the epidural needle is a major challenge. To address this, we developed a forward-view endoscopic optical coherence tomography (OCT) system for real-time imaging of the tissue in front of the needle tip during the puncture. We tested this OCT system in porcine backbones and developed a set of deep learning models to automatically process the imaging data for needle localization. A series of binary classification models were developed to recognize the five layers of the backbone, including fat, interspinous ligament, ligamentum flavum, epidural space, and spinal cord. The classification models provided an average classification accuracy of 96.65%. During puncture, it is important to maintain a safe distance between the needle tip and the dura mater. Regression models were developed to estimate that distance based on the OCT imaging data. Based on the Inception architecture, our models achieved a mean absolute percentage error of 3.05% ± 0.55%. Overall, our results validated the technical feasibility of using this novel imaging strategy to automatically recognize different tissue structures and measure the distances ahead of the needle tip during the epidural needle placement.

Battery swallow-induced tracheoesophageal fistula in a pediatric patient.

Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. Rare acquired TEF arises from trauma, caustic fluids ingestion, and iatrogenic injuries (ventilation, esophageal atresia repair, radiation, or tracheal/esophageal stents). We discuss the diagnosis, anesthetic management, and surgical correction of battery swallow-induced TEF, not previously reported in the pediatric anesthesia and otorhinolaryngology literatures.

A multicenter study to evaluate the pharmacokinetics and safety of liposomal bupivacaine for postsurgical analgesia in pediatric patients aged 6 to less than 17 years (PLAY).

STUDY OBJECTIVE: To evaluate the pharmacokinetics and safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. DESIGN: Multicenter, open-label, phase 3, randomized trial (PLAY; NCT03682302). SETTING: Operating room. PATIENTS: Two separate age groups were evaluated (age group 1: patients 12 to <17 years undergoing spine surgery; age group 2: patients 6 to <12 years undergoing spine or cardiac surgery). INTERVENTION: Randomized allocation of liposomal bupivacaine 4 mg/kg or bupivacaine hydrochloride (HCl) 2 mg/kg via local infiltration at the end of spine surgery (age group 1); liposomal bupivacaine 4 mg/kg via local infiltration at the end of spine or cardiac surgery (age group 2). MEASUREMENTS: The primary and secondary objectives were to evaluate the pharmacokinetics (eg, maximum plasma bupivacaine concentrations [Cmax], time to Cmax) and safety of liposomal bupivacaine, respectively. MAIN RESULTS: Baseline characteristics were comparable across groups. Mean Cmax after liposomal bupivacaine administration was lower versus bupivacaine HCl in age group 1 (357 vs 564 ng/mL); mean Cmax in age group 2 was 320 and 447 ng/mL for spine and cardiac surgery, respectively. Median time to Cmax of liposomal bupivacaine occurred later with cardiac surgery versus spine surgery (22.7 vs 7.4 h). In age group 1, the incidence of adverse events (AEs) was comparable between liposomal bupivacaine (61% [19/31]) and bupivacaine HCl (73% [22/30]). In age group 2, 100% (5/5) and 31% (9/29) of patients undergoing spine and cardiac surgery experienced AEs, respectively. AEs were generally mild or moderate, with no discontinuations due to AEs or deaths. CONCLUSIONS: Plasma bupivacaine levels following local infiltration with liposomal bupivacaine remained below the toxic threshold in adults (~2000-4000 ng/mL) across age groups and procedures. AEs were mild to moderate, supporting the safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. Clinical trial number and registry URL: ClinicalTrials.gov identifier: NCT03682302.

Anesthesia Management for Pediatric Patient With Multiple Endocrine Neoplasia Type 2B: A Case Report.

Administering anesthesia to patients with pheochromocytoma may cause an exacerbation of catecholamine secretion from the pheochromocytoma secondary to drug administration, stress, or manipulation of the tumor. We present a pediatric patient with undiagnosed multiple endocrine neoplasia type 2B (pheochromocytoma, thyroid carcinoma, and mucosal neuromas), initially diagnosed and treated for postviral myocarditis and cardiomyopathy, who presented for abdominal magnetic resonance imaging (MRI) under general anesthesia. Untreated cardiomyopathy poses an extra anesthesia mortality risk for patients with pheochromocytoma usually due to myocardial failure, myocardial infarction, or hypertensive hemorrhage into the myocardium or brain.

Safe general anesthesia in a hyperkalemic infant.

A 10-day-old boy treated in the intensive care unit and operating room due to hyperkalemia and renal failure. After admission to the intensive care unit and treatment for hyperkalemia, the patient required insertion of dialysis catheter in the operating room. Treatment for hyperkalemia continued while the patient was under general anesthesia. The operation was carried out successfully and cardiac signs and symptoms of hyperkalemia did not occur despite of potassium blood levels of 8.1 mEq x l(-1). General anesthesia could be safe in hyperkalemic patients as long as the treatment for hyperkalemia is initiated before and during the surgery and hyperkalemia inducing agents are avoided.

Carbamazepine interacts with a slow inactivation state of NaV1.8-like sodium channels.

Carbamazepine was tested on high-threshold TTX-resistant Na+ currents (TTX-R-currents), evoked from acutely isolated rat dorsal root ganglion (DRG) cells. Under control conditions, the TTX-R-currents recorded from different DRG cells varied greatly regarding use-dependent inactivation (TTX-R-current UDI), measured as the percent decrease in current amplitude induced by changing the current activation rate from 0.1 Hz to 1.0 Hz. Also, when TTX-R-currents were evoked at 0.1 Hz from a holding potential (hp) of -60 mV, a larger fraction of TTX-R-channels resided tonically in a slow inactivation state in DRG cells with more TTX-R-current UDI versus those with less TTX-R-current UDI. The block of TTX-R-currents evoked from hp -60 mV by 100-microM carbamazepine and the EC50 for carbamazepine block was positively correlated with TTX-R-current UDI. The slope factors estimated for the concentration-response curves averaged 0.68, suggesting the presence of low and high affinity sites. Fitting the data with a two-site binding isotherm gave estimates of 30 microM and 760 microM for the EC50s of the high and low affinity sites, respectively. The fraction of the total fit attributed to the high affinity site was positively correlated with TTX-R-current UDI. Carbamazepine increased the fast and slow time constants for recovery from inactivation and the fraction of the fit attributed to the slow time constant. These data suggest that carbamazepine interacts with a slow inactivation state of TTX-R-channels. This particular mechanism might be exploited in future research aimed at developing pain medications that selectively block Na(V)1.8 channels or Na+ channels in general.

A randomized, single-blinded, prospective study that compares complications between cuffed and uncuffed nasal endotracheal tubes of different sizes and brands in pediatric patients.

STUDY OBJECTIVE: To compare any association between the problematic distal placement of cuffed and uncuffed nasal endotracheal tubes (NETTs) of different sizes and brands in pediatric patients. DESIGN: Randomized, single-blinded, prospective study. SETTING: Operating room at The Children's Hospital. PATIENTS: Pediatric patients (aged 2-18 years) scheduled for dental surgery under general anesthesia whose American Society of Anesthesiologists physical status is not greater than 2. INTERVENTION: Patients were randomly assigned to preformed cuffed (1) RAE (Ring-Adair-Elwyn) endotracheal tube by Mallinckrodt or (2) nasal AGT NETT by Rüsch. MEASUREMENTS: The distance between the tube's distal end and the carina was measured using a fiber optic bronchoscope. Problematic placements were defined where the tip of the tubes was within 0.5 cm of carina. MAIN RESULTS: The odds of a problematic placement was 7 times higher (95% confidence interval of odds ratio, 2.06, 23.4) in patients managed with cuffed tubes than those with uncuffed tubes (P = .002). The distance between the tip of cuffed NETT tubes and carina was significantly less than with uncuffed tubes. CONCLUSIONS: The chances of possible complications were significantly higher with cuffed NETT. The NETT should be kept at least 0.5 cm above carina to avoid possible complications.

Failed calibration of anesthesia machine due to look-alike oxygen sensors.

Labels and medications with similar appearances have the potential to harm patients and cause delays in hospital services. We report a problem involving the Maxtec MAX-1 and MAX-11 oxygen sensors which are commonly used on anesthesia machines. These oxygen sensors have nearly identical labels which resulted in inadvertent interchanging of the sensors. The incident required the replacement of a MAX-11 sensor with a MAX-1 sensor to ensure proper functioning of the anesthesia machine. Identification of these cases can educate health care professionals of potential sources of labeling errors and safety issues and can also bring about Food and Drug Administration policy changes.

Does the covering of children during induction of anesthesia have an effect on body temperature at the end of surgery?

STUDY OBJECTIVES: To determine whether the covering of healthy children during anesthetic induction reduces hypothermia at the end of minor surgeries. DESIGN: Randomized, single-blinded, prospective study. SETTING: Operating room and postoperative recovery area of a university-affiliated hospital. PATIENTS: 50 ASA physical status 1 patients, aged 6 months to 3.5 years, scheduled for simple urological surgeries. INTERVENTIONS: Subjects were randomly assigned to one of two groups: covered or uncovered. Children in the covered group (Group C) were actively warmed on arrival in the operating room (OR) using cotton blankets and a warm forced-air blanket set at 43°C. Children in the uncovered group (Group U) remained uncovered during the induction of general anesthesia. Children in both groups were actively warmed following placement of surgical drapes. MEASUREMENTS: Temperature (in Celsius) during the study procedure was recorded for each patient. MAIN RESULTS: Mean core body temperature at the end of induction did not differ in the two groups, 36.4°C in Group C and 36.6°C in Group U. Mean core body temperature at the end of surgery did not differ between the two groups: 36.9°C in Group C and 37.0°C in Group U. CONCLUSION: Leaving healthy children uncovered during induction of general anesthesia does not have a clinically significant effect on core temperature at the end of induction or of surgery.

Profound intraoperative metabolic acidosis and hypotension in a child undergoing multilevel spinal fusion.

The prone position may cause cardiovascular system depression. Yet, the mechanisms involved and preemptive measures are not well understood (Edgcombe et al. (2008)). During spinal surgery in the prone position, hypotension may occur. Implicated factors include prolonged abdominal compression impeding venous return resulting in increased blood loss, decreased cardiovascular reserve, and the use of total intravenous anesthesia (TIVA) which has been shown to blunt the sympathetic response more than inhalation anesthesia. We present a case of hypotension during spinal surgery with all its challenges. Hypotension and acidosis persisted despite all supporting measures, and only to improve with supine positioning. Differential diagnosis for such an event are discussed. Although abdominal compression may not be obvious before the start of surgery, compressing the spine during surgery may lead to abdominal compression and hypoperfusion to abdominal organs.